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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017823
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:15:22 PM

Document Has Been Signed on 12/22/2021 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KIDS KLUB CHILD DEVELOPMENT CENTERSFACILITY NUMBER:
198017823
ADMINISTRATOR:WOJCIECHOWSKI, MICHAELFACILITY TYPE:
840
ADDRESS:1515 GARFIELD AVE.TELEPHONE:
(626) 795-2501
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 38DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Castillo, Ed CoordinatorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) conducted a case management inspection due to an incident that occurred on 12/16/2021. LPA met with Education Coordinator Samantha Castillo. Site Director, Stephanie Velasquez was not available at the time of arrival but arrived during the inspection. LPA conducted interviews and obtained documentation during this visit.

At the time of arrival, LPA observed 38 children with 4 staff. Staff to children ratios were observed to be in accordance with Title 22 regulations.

The incident which occurred on 12/16/21 was reported to the Department on 12/20/21 via telephone. The facility did not report the incident in a timely manner. Per Regional Director, Ms. Rudman who also arrived for the inspection and stated that she called the following day to report to OD when mom said that Jeremy said it happened at Kids Klub.

On 12/16/20 Child #1 was lifting his arm to get a pencil and the Staff #1, saw a red scratch on child’s back. Teacher lifted child’s shirt and noticed the mark was a scratch 8 inches long on his spine and it was scabbed with dried blood. Staff #1 asked child how it happened, and child first said at school, then at home and then at Kids Klub. When child was asked when it happened, child said it happened today. Child was at the facility 45 minutes prior to Teacher noticing scratch. Facility reported the incident to DCFS.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
At this time, the facility is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued. Exit interview was conducted with Director Stephanie Velasquez and Regional Director, Debbie Rudman. Appeal rights explained & provided.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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